The Statement of Information is a Vermont Department of Health form, issued by its Vital Records Office in Waterbury, that sets out the information to appear on a delayed certificate of birth under 18 VSA § 5075(b). It collects details about the child, the mother or parent and the father or parent, and ends with the applicant's signature and a notary's sworn statement. On FillingPDF you can fill out the form online and download or print the completed PDF; the original form is published by the Vermont Department of Health, and delivery follows the agency's own channels.
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What is Statement of Information to Appear on Delayed Certificate of Birth – Vermont?
The Statement of Information to Appear on Delayed Certificate of Birth is the Vermont Department of Health form that lists the child's and parents' details to appear on a delayed certificate of birth, made pursuant to 18 VSA § 5075(b) and sworn before a notary public.
The form is issued by the Vital Records Office, 280 State Drive, Waterbury, VT 05671-8370, and the edition printed on it is February 2024. It has one page of entries in five blocks:
- Child's Information: name (first, middle, last, suffix), date of birth, sex and city or town of birth.
- Mother's/Parent's Information: name at the time of the child's birth, last name at the parent's birth, date of birth, U.S. state or foreign country of birth, and residence at the time of birth.
- Father's/Parent's Information: name at the time of the child's birth, date of birth, and U.S. state or foreign country of birth.
- Applicant's Signature: signature, date signed, printed name and relationship to the child named on the certificate.
- A notary block: the date it was signed and sworn, the notary's signature and the notary's expiration date.
It is not an order form for copies of a birth certificate. The Department's separate page on ordering Vermont vital records covers certified and noncertified copies, which are requested through a different process.
Who needs to file Statement of Information to Appear on Delayed Certificate of Birth – Vermont?
The form is completed by the applicant who is providing the information that will appear on a delayed certificate of birth in Vermont. The applicant identifies themselves on the form by printed name and by relationship to the child named on the certificate, so the form is not limited to the person whose birth is recorded.
You will need these details to complete it:
- The child's full name, date of birth, sex and city or town of birth.
- For the mother or parent: the name at the time of the child's birth, the last name at that parent's own birth, date of birth, U.S. state or foreign country of birth, and the city or town and state of residence at the time of birth.
- For the father or parent: the name at the time of the child's birth, date of birth, and U.S. state or foreign country of birth.
The form does not say who is eligible to be an applicant or what other evidence the Vital Records Office may require for a delayed certificate. Ask the office before you sign if you are unsure whether you can be the applicant.
How to fill out Statement of Information to Appear on Delayed Certificate of Birth – Vermont
Confirm the form and edition
Check that the title reads Statement of Information to Appear on Delayed Certificate of Birth, pursuant to 18 VSA § 5075(b), and the edition is February 2024.
Enter the child's name
Under Child's Information, enter the child's first, middle and last name and suffix in the Name boxes.
Enter the child's birth details
Fill in the child's Date of Birth, mark Male or Female for Sex, and enter the City or Town of Birth.
Complete the mother's or parent's block
Enter the name at the time of the child's birth, the Last Name at Parent's Birth, the Date of Birth, and the U.S. State or Foreign Country of Birth. Then enter the Residence at Time of Birth: City or Town and State.
Complete the father's or parent's block
Enter the name at the time of the child's birth, the Date of Birth, and the U.S. State or Foreign Country of Birth.
Identify the applicant
Under Applicant's Signature, enter your Print Name and your Relationship to Child Named on Certificate.
Sign, date and have it notarized
Sign and enter the Date Signed. The notary completes the sworn statement: the date, the Signature of Notary Public and the Expiration Date.
Review and download the completed PDF
Check every name and date against your records, then download or print the completed PDF from FillingPDF and deliver it through the Vermont Department of Health's channels described under How to submit.
How to submit Statement of Information to Appear on Delayed Certificate of Birth – Vermont
The form prints no submission channel of its own. Its letterhead names the Vital Records Office of the Vermont Department of Health, 280 State Drive, Waterbury, VT 05671-8370, which is the office that issues it. The sworn statement means the signed and notarized original is what you hold, so confirm with the Vital Records Office how it wants the form delivered, and in what way, before you send it.
The Department's page on ordering vital records tells applicants to follow the instructions on the application they choose and to mail it to the address stated on that application; this statement does not print such an instruction, and that page concerns requests for copies of records, not delayed certificates.
FillingPDF lets you fill out and download the PDF; submission follows the channels of the Vermont Department of Health.
Common mistakes to avoid
- Leaving the notary block blank: the form says it is signed and sworn before a notary public, with the date, the notary's signature and the notary's expiration date.
- Entering the parent's current name on the last-name line for the parent's own birth; the form asks separately for the name at the time of the child's birth and the last name at the parent's birth.
- Omitting the mother's or parent's residence at the time of birth (city or town and state), which is the one block that asks for it.
- Skipping the applicant's printed name or the relationship to the child named on the certificate.
- Leaving the applicant's signature or the Date Signed line empty.
- Treating the form as a request for a copy of a birth certificate; copies are ordered through the Department's separate vital records ordering process.
Frequently asked questions
What is a statement of information for a Vermont delayed birth certificate?
It is a Vermont Department of Health form, issued by the Vital Records Office under 18 VSA § 5075(b), that sets out the child's and parents' details to appear on a delayed certificate of birth. It is signed by the applicant and sworn before a notary public.
Does the Statement of Information have to be notarized?
The form includes a block reading "Signed and sworn to before me," with a date, the notary public's signature and the notary's expiration date. Complete the applicant section and have the notary complete that block.
What information does the form ask for?
It asks for the child's name, date of birth, sex and city or town of birth. It also asks for the mother's or parent's and father's or parent's names, birth dates and places of birth, plus the mother's or parent's residence at the time of birth.
Can I fill out the Statement of Information online?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not file the form; you deliver it through the Vermont Department of Health's channels.
Where is the Vermont Vital Records Office?
The form's letterhead gives the Vital Records Office at 280 State Drive, Waterbury, VT 05671-8370. The form prints no separate mailing or submission instructions, so confirm delivery details with that office.
Is this the form to order a copy of a Vermont birth certificate?
No. This statement supports a delayed certificate of birth. The Department's ordering page covers certified and noncertified copies through a Town or City Clerk, online or by mail, using the applications listed there.
What is the difference between the two parent name lines?
The form asks for the mother's or parent's name at the time of the child's birth, and separately for the last name at that parent's own birth. Enter each as asked; the father's or parent's block asks only for the name at the time of the child's birth.
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